Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-032Assessment of Daily LivingKerstin Hulter AsbergUniversity of Uppsala, SwedenThe need for assessing activities of daily living 1 (ADL) hasincreased during the last few decades for several reasons. First,the number of disabled persons in the population is higher todaythan ever before, since more people survive longer and have tolive with the consequences of diseases and other 2 disorders.Second, the costs for ADL-related services to disabled personshave surged ahead, both for sheltered living and for assistancegiven by people paid to provide services in the homes. Relativesand neighbours will often give voluntary help but they, too, mayneed professional support. Third, there is a need for outcomemeasures, other than mortality and morbidity, which candescribe levels of function among elderly people. This is requiredfor the evaluation of pharmacological treatments and rehabilitationprogrammes. Many people in different professions areinvolved in the care of the elderly, e.g. physicians, nurses,occupational therapists, physiotherapists and social workers. Inclinical practice, they need a common language to communicatetheir knowledge about the individual’s functional level. Althoughmuch work has already been done to develop new ADLinstruments and make existing ADL assessments representative,reliable and valid, much remains to be done to reach a consensusin this field. Even a definition of the concept of ADL can still bea matter for discussion: ‘‘ADL’’ means ‘‘activities which arecommon to all human beings and which must be performedregularly in order to live an independent life’’. This is a verybroad definition, which permits a variety of activities to beincluded. These activities are usually divided into severalcategories:1. Personal ADL: activities concerning self-care, care of one’sown body, e.g. feeding, dressing, bathing.2. Instrumental ADL: activities concerning home management,e.g. cooking, cleaning, shopping.(Communication by talking and writing may be referred to aspersonal ADL, while transportation and managing money maybe referred to as instrumental ADL.)3. Professional work.4. Leisure activities.Ambulation or walking is not an ADL item, although it is oftenassessed in this context. It is rather a level of mobility on a scalefrom bed-ridden, through unsteady gait such as creeping, towalking and running. A certain level of mobility is usuallyrequired for independent living as is a certain level of intellectualcapacity, motivation and a suitable environment.‘‘ADL-capacity’’ means that a subject can perform ADLindependently of another person. Even if a person can dothings, it may not be certain that he/she actually does them inpractice! In the WHO Classification of Impairments, Disabilitiesand Handicaps, ADL-dependence is classified as a disability.‘‘Disability’’ has been defined as ‘‘any restriction or lack(resulting from impairment) of ability to perform an activityin the manner or within the range considered normal for thehuman being’’ 2 .‘‘ADL-ability’’ means that a subject does perform ADL. It maytake time, it may hurt, or there may be other difficulties, but theperson is nevertheless able to perform ADL and independently ofanother person. If a person does not perform ADL, it may be dueto physical or intellectual capacity deficits (he/she can not or doesnot understand) but it may also be due to lack of motivation (he/she does not want to do it), or to environment problems (he/she isnot allowed to do it or is prevented).When assessing ADL-performance in clinical practice, it isrecommended that the interviewer starts with the question: ‘‘Doesthe patient perform the activity or not?’’ If he/she does not or hasdifficulties, the interviewer may proceed by asking ‘‘Why shouldthis be?’’ There may be physical, mental and/or social reasons,which then must be analysed in more detail to form the basis fordecisions on rehabilitation.‘‘ADL assessment’’ is part of the broader concept of ‘‘functionalassessment’’, which implies assessment not only of disabilitybut also of impairments and handicaps. ‘‘Functional assessment’’is to be found in DSM-III-R and in DSM-IV 19 in Axis V. TheGlobal Assessment of Functioning (GAF) scale is a hierarchicalassessment scale not only of psychic symptoms but also of socialand professional functioning.The ADL instruments can be constructed as check lists, asummed index or hierarchical scales.WHAT IS AVAILABLE TO ASSESS ACTIVITIES OFDAILY LIVING?Many structured ADL assessment instruments have been developedbut rather few have been used by persons other than theirinventors. Most instruments include the same types of personalitems, but they often have divergent operational definitions, ifindeed they are defined at all. Some instruments combine personaland instrumental items. There are also multidimensional instrumentswith ADL items mixed up with those for other assessments,such as mobility, physical status, mental capacity and socialconditions.An overview of such instruments, mainly from Anglo-Saxoncountries, is given in Kane and Kane 4 . This field of study is alsoundergoing continuous and rapid development in other countries,so readers are recommended to check up on the key-word‘‘Activities of Daily Living’’ in Index Medicus.Principles and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd